Wiggleswell Canine Rescue
PROSPECTIVE OWNER ADOPTION INFORMATION REQUEST

00. The name of the animal you want:
0. Your e-mail:
1. Your name:
2. Your address:
City:
State: Zip:
3. Your phone number:
4. Are you over 18?
5. Your occupation and work schedule:
6. Are you married? Number of children and their ages:
7. Please list breed, age, and sex of all dogs currently in your household:

8. Are these dogs spayed or neutered? If NOT, please explain why not:

9. How long have you owned each dog?
10. How many cats, if any, share your household?
11. Are these cats spayed or neutered? If not, please explain why not:

12. Please provide the name, full address and phone number, with area code, of at least one veterinarian reference that is handling your pets annual/maintenance medical care:
Vet Name:
Vet Address:
City State: Zip:
Phone number
13. How do you treat your animals to protect them against HEARTWORMS?

14. Your driver's license number: State:
15. The name of your employer:
16. Do you live in a house, apartment, duplex, trailer, or other? Do you own or rent?
17. If you rent, do you have permission from the landlord to have a dog at your residence?
18. How many people live in your household? Adults? Children?
Please list their ages:
19. Is everyone in the household in favor of adopting a pet?
20. Where will this pet reside?
21. Do you have a fenced yard? If so, what TYPE of fence do you have? What is the height of the fence?
22. What type of shelter will the pet have?
23. Where will this pet spend the most time? Inside? Outside?
24. Where will this pet stay when you and/or the family is not home?
25. If you have had pets in the past but no longer have them, briefly share how long you had them and what happened to them:

26. Are all of the pets that you have NOW, current on their vaccinations?
27. If this pet becomes ill/injured, do you have the means to cover medical costs?
28. Briefly explain why you want to adopt this pet:

29. What would constitute a reason for giving up this pet?

30. Would you object a home visit PRIOR to adoption?
31. Would you object a home visit AFTER the adoption?
32. Please provide two personal references whom we may contact. References should know you, your home and record of pet care, and, preferably should be UN- RELATED to you. Please provide names, addresses and complete phone numbers, including area codes.

Reference one Name: Phone Number:
Address:
City: State: Zip:

Reference two Name: Phone Number:
Address:
City: State: Zip:

Thank you for taking the time to fill out this form. All information requested is helpful in matching prospective homes with the right pet. Upon receipt of this information, we will try to get back to you as quickly as possible.

DISCLAIMER

There is NO guarantee made, express or implied, that any person requesting to adopt a dog through Wiggleswell Canine Rescue will automatically be approved. All adoptions are subject to acceptance base on a review process that requires collecting information from references and visiting the applicant's home. Wiggleswell Canine Rescue reserves the right to refuse to adopt to anyone without disclosing the reasons.

PLEASE NOTE: BY COMPLETING THIS APPLICATION AND PROVIDING A VET REFERENCE, YOU ARE GIVING Wiggleswell Canine Rescue EXPRESS AUTHORIZATION TO CONTACT AND CONFIRM SAID VET CARE OF YOUR CURRENT ANIMALS.

Signature:______________________________________ Date:_____________________